Rooted in mistrust? Covid-19’s march into rural India is a very different ball game

By Sudhir Katiyar*
As the Covid-19 virus penetrates rural India, the rural communities are responding very differently from their urban counterparts who rushed to the hospitals. The rural communities are avoiding the public health facilities and any mention of the disease. The note argues that this supposedly irrational response is based on a deep-seated mistrust of the state by the rural communities. It can not be resolved with routine Information, Education and Communication (IEC) measures suggested in the Government of India SOP for tackling Covid-19 in rural areas.
It is now acknowledged by all that the second wave of Covid-19 has reached rural India. Acknowledging the ingress of Covid-19 into rural areas, the Central Government issued Standard Operating Procedure (SOP) on Covid-19 Containment & Management in Peri-urban, Rural & Tribal Areas on May 16. The SOP proposes a three-tier structure from Covid Care Centre (CCC) to manage mild or asymptomatic cases, Dedicated Covid Health Centre (DCHC) to manage moderate cases and Dedicated Covid Hospital (DCH) to manage severe cases.
However, management of Covid-19 in rural areas is going to be a very different ball game. As Covid-19 marches headlong into rural India, a strange paradox manifests itself. The urban India saw an acute shortage of oxygen, ICU beds and ventilators as Covid infected patients in serious condition rushed to the hospitals. The pandemic also reasserted the primary role of public health systems in health care as it took the lead in managing the pandemic.
By contrast, the reality in rural India is completely different. While there are already reports of large number of deaths taking place, the rural communities are avoiding the public health facilities like plague. The public health system was never much functional anyway in rural India except for some notable exceptions like Kerala and Tamil Nadu. Rural PHCs remain unstaffed and the infrastructure created falls into ruins.
The number of functional rural PHCs in any district can be counted on finger tips. However, the Covid-19 pandemic has seen rural people enforcing an almost complete boycott of Government facilities. The people fear being tested and if positive, being confined to isolation facilities from which, they fear, chances of coming out alive are slim. In absence of any credible medicine to treat the infection, vaccination has emerged as the only strategy to manage the epidemic. While urban India has embraced vaccines, there is extreme vaccine hesitancy in rural areas.
A rapid assessment by the Centre for Labour Research and Action amongst migrant workers across eight migration streams in Gujarat and Rajasthan revealed that 80 percent respondents did not want to get vaccinated. The rumour mills abound. The disease has been spread by the state to kill off old people, pensioners, organs are being removed, it will not affect rural people, vaccine itself causes disease.
The SOP does have a component called Community mobilization and behavior change. It seeks to use the village level health workers, the panchayat raj and other Government functionaries, and Village Health Sanitation and Nutrition Committees. The last most probably exist only in papers in most places.
However, the behaviour and response of the rural communities is rooted in a deep mistrust of the state that is centuries old. It cannot be done away with the normal IEC type campaigns. Writing in "Autobiography of An Unknown Indian" 75 years ago, Nirad C Chaudhry wrote, "For centuries the political creed of the Indian peasant and the Indian worker has consisted of one single article, never to trust the professions, the motives and doing of their rulers. This distrust of the state and ruling order is virtually ineradicable". 

It is clear that nothing has changed in the last 75 years of independence to change this perception. To quote a Hindi couplet: "Ka nrip hoye, hamen kya haani" (Whoever is the ruler, how does it matter to us?).

Village people burning their own dead without any autopsies is fine as long as they do not start floating the bodies in the river

It is this division, that is sometimes framed as a division between India and Bharat, but it is actually a division between the powerful and the powerless, a division between the Savarnas and the Shudras, a division between the working classes and those who profit from their labour. It is a division that has stood firm for the last two millennia.
The middle classes have made sure that the ingress of modernity – education, health, dignified living, and social security – stop at their door step. To illustrate one only has to look at the state of basic education, the primary means of ushering in modernity. While the ruling elite sends its own children to private schools, it has made sure that the public schooling system becomes dysfunctional.
The Annual Survey of Education Reports (ASERs) that capture state of schooling in India, reveal that educational achievements in Government schools have been falling in the last decade. What needs a behavior change is the attitude of the middle classes not the rural communities.
The response of the rural communities suits the state very well. It is not likely to rock the boat besides issuing SOPs and making some formal noises. It is anyway facing a tough job in hiding deaths in cities with footage of funeral pyres adorning pages of national and international journals. 

Village people burning their own dead without any autopsies is fine as long as they do not start floating the bodies in the river. Then the state will employ its vast security apparatus for ensuring that these do not come to light. Sickness in rural areas remaining away from the limelight is good. As long as the large number of deaths do not get highlighted, it is fine.

Writing in "Indian Express" of May 18 in an article titled 'Virus in the Village', Dr KS Reddy, President of the Public Health Foundation of India, expressed the hope that perhaps the design of a new health system will emerge from the Covid crucible to serve as the platform for universal health coverage. Unless the liberal intelligentsia factors in this deep mistrust, and the ruling classes change their mindset, this hope is likely to remain a hope only.
---
*Centre for Labour Research and Action, Ahmedabad